Chronic subdural hemorrhage is defined as a collection of blood in the subdural space that persists for more than three weeks. Given the aging global population, its incidence is rising. Its incidence ranges from 1 to 5.3 per 100,000 individuals annually, with increased prevalence in the elderly1. It predominantly affects older adults due to brain atrophy, increased venous fragility, and anticoagulant use. CSDH accounts for up to 10% of all intracranial hematomas. CSDH is primarily associated with cerebral atrophy, which renders bridging veins more susceptible to rupture following even minor head trauma. Risk factors include advanced age, chronic alcohol abuse2, repeated head injuries (frequent in prisoners), and neurological conditions such as cerebral palsy (CP), hypoxic-ischemic encephalopathy (HIE), and untreated congenital hydrocephalus. Additionally, patients on anticoagulant therapy or with coagulopathies3, such as those with chronic kidney disease (CKD), are at increased risk. The pathophysiology of CSDH begins with the rupture of bridging veins, often triggered by a seemingly trivial injury. Initial bleeding usually halts spontaneously and causes no immediate symptoms or mass effect. However, several mechanisms may contribute to hematoma expansion and symptom onset4. One early theory suggests that liquefaction of the hematoma over several weeks leads to an increase in osmotic pressure, drawing fluid from the cerebrospinal fluid (CSF) and surrounding tissues5. Another hypothesis involves repeated minor trauma, causing recurrent hemorrhage and layering of blood at different stages. A more widely accepted mechanism involves the formation of a vascularized membrane around the hematoma that actively secretes fluid. Additionally, fragile neocapillaries in this membrane can rupture, contributing to hematoma enlargement. According to Ito et al., new hemorrhages account for about 6.7% of the hematoma content. Chronic alcoholics are especially vulnerable due to platelet dysfunction and coagulation abnormalities. As the hematoma slowly enlarges, it may remain clinically silent for weeks due to compensatory cerebral atrophy6. Eventually, increasing pressure compromises cortical perfusion, leading to symptoms such as reduced consciousness, motor deficits, and cognitive changes. Surgical evacuation relieves the mass effect and often restores neurological function. The clinical presentation of CSDH is diverse and depends on the rate of hematoma expansion and the patient’s neurological reserve. Common symptoms in the elderly include altered sensorium, urinary incontinence, and motor weakness. In relatively younger patients, progressive headaches and vomiting are more frequent. Less commonly, patients may present with hemianaesthesia, gait disturbances, diplopia, or memory loss7,8. A high index of suspicion is necessary, particularly in older patients with a history of minor head injury or chronic alcohol use. Diagnosis is typically confirmed by a non-contrast CT scan of the head, which reveals a crescent-shaped, iso- or hypodense collection over the cerebral hemisphere, effacement of cortical sulci, and potential midline shift9,10. In cases with isodense or bilateral hematomas or when CT findings are inconclusive, contrast-enhanced CT or MRI is beneficial to detect internal septations, multiloculations, or differentiate from other extra-axial masses11. AIM Management of chronic subdural haemorrhage .

This retrospective observational study was conducted in the Department of Neurosurgery at over a period of 2 year 4 month (March 2023 to June 2025). A total of 75 patients diagnosed with chronic subdural hematoma (CSDH) based on clinical evaluation and neuroimaging findings were included. Data were collected from medical records, including patient demographics, presenting symptoms, type and laterality of hematoma, surgical procedures performed, and clinical outcomes. Inclusion criteria comprised patients aged >12 years with a radiologically confirmed diagnosis of chronic or acute-on-chronic subdural hematoma, who underwent either conservative or surgical management. Patients with traumatic acute SDH, intracerebral hemorrhage, or incomplete records were excluded. Surgical interventions included burr hole craniostomy, mini craniotomy, or decompressive craniotomy, selected based on hematoma characteristics and neurological status. Postoperative outcomes, recurrence rates, complications, and mortality were recorded and analyzed.

Table 1: Age criteria of cases: Age Number Percentage <20 1 1% 21-30 2 3% 31-40 4 5% 41-50 7 10% 51-60 15 20% 61-70 19 25% 71-80 19 25% 81-90 8 11% In the present study on Chronic Subdural Hematoma (CSDH), the age distribution of cases showed that the majority were in the age groups 61–70 years and 71–80 years, each accounting for 25% (19 cases) of the total. This was followed by 20% (15 cases) in the 51–60 age group, 11% (8 cases) in the 81–90 group, and lower percentages in younger age groups: 10% (7 cases) in 41–50, 5% (4 cases) in 31–40, 3% (2 cases) in 21–30, and 1% (1 case) below 20 years. Table 2: Gender of cases: Gender Number Percentage Male 63 84% Female 12 16% In the present study on Chronic Subdural Hematoma (CSDH), a marked male predominance was observed, with 84% (63 cases) being male and only 16% (12 cases) female, indicating that CSDH is significantly more common in males. Table 3: Presentation Symptoms: Symptoms Number (n) Percentage (%) Headache 45 60% vomiting 16 21% Intermittent Convulsion 7 9% Brief loss of consciousness 9 12% Altered sensorium 18 24% Blurring of vision 2 3% Hemi paresis/Limb weakness 11 15% History of recent trauma 37 50% In our study, the most common presenting symptom was headache (60%), followed by a history of recent trauma in 50% of patients. Other symptoms included altered sensorium (24%), vomiting (21%), limb weakness (15%), brief loss of consciousness (12%), intermittent convulsions (9%), and blurring of vision (3%). Table 4: Diagnosis of cases: Diagnosis Number Percentage B/l ftp chr sdh 10 14% B/l ftp acute on chr sdh 1 1% B/l ftp chronic sdh 1 1% Lt ftp acute on chr sdh 4 6% Lt ftp chr sdh 24 32% Lt ftp chr sdh with septation 1 1% Rt ftp acute on chr sdh 4 6% Rt ftp chr sdh 30 40% In the current study, the most common diagnosis among CSDH cases was right frontotemporoparietal (FTP) chronic subdural hematoma, observed in 40% (30 cases), followed by left FTP chronic SDH in 32% (24 cases). Other diagnoses included bilateral FTP chronic SDH (14%), left FTP acute on chronic SDH (6%), right FTP acute on chronic SDH (6%), and a few rare variants such as bilateral FTL acute on chronic SDH and septated hematomas, each comprising 1% of cases. Table 5: Procedure done on cases: Procedure Number Percentage B/l fp burr 8 11% Lt fp burr 25 33% Rt fp burr 29 39% Lt and rt fp burr 2 3% B/l. mini craniotomy 1 1% Lt fp mini craniotomy 5 7% Rt fp mini craniotomy 3 4% Rt fp decompression craniectomy 1 1% Lt fp decompression craniectomy 1 1% In this study, the most commonly performed procedure for CSDH was right frontoparietal (FP) burr hole evacuation in 39% (29 cases), followed by left FP burr hole in 33% (25 cases) and bilateral FP burr holes in 11% (8 cases). Less frequently performed procedures included mini craniotomies and decompression craniectomies on various sides, each accounting for 1–7% of cases. Table 6: Clinical results in cases: Clinical results Number Percentage Septation 1 1% Recurrent 5 6.7% Acute on chronic 9 12% Death 6 8% Among the CSDH cases, Acute on chronic presentations 12% (9 casses),6.7% (5 cases) of the "others" category were recurrences, while deaths were reported in 8% (6 cases). Septated hematomas accounted for 1% (1 case) of the total.

The literature supports surgical evacuation via burr hole as the primary modality for symptomatic CSDH. Adjuncts such as drains and pharmacologic agents show promise in reducing recurrence and improving outcomes. However, variability in patient age, comorbidities, and hematoma characteristics necessitate individualized treatment planning. There is growing interest in medical therapies, which may benefit patients unfit for surgery or as adjuvants to reduce recurrence. In our study, the majority of patients with chronic subdural hematoma were aged between 61–80 years, accounting for 50% of cases. The 51–60 age group contributed 20%, while 41–50 years comprised 10%. Younger patients below 40 years made up only 9% of the cohort. The least affected were those under 20 years, representing just 1% of the cases. In a study done by Gelabert-González12 the series included 1000 cases , age range 12-100 years, mean age 72.7+/-11.4 years. In our study, males were predominantly affected by chronic subdural hematoma, comprising 84% of the cases. Females accounted for only 16% of the total patients. The gender disparity may be attributed to higher exposure to trauma, alcohol use, and vascular risk factors among males. The condition showed a strong male preponderance in our cohort. In a study done by Kurmi13 a total of 52 patients were included in the study. Male and female ratio was 3: 1. In our study, headache was the most common presenting symptom, reported in 60% of patients, followed by a history of recent trauma in 50%. Altered sensorium was seen in 24% of cases, while vomiting occurred in 21%. Hemiparesis or limb weakness was present in 15% of patients, and brief loss of consciousness was noted in 12%. Intermittent convulsions were reported in 9%, and blurring of vision in 3%. The range of symptoms highlights the variable and often subtle clinical presentation of chronic subdural hematoma .In a study done by Kurmi DJ13 headache was the most common symptom followed by altered sensorium, limb weakness, intermittent vomiting, convulsions and others (Table-2). History of recent trauma in 35 (67.31 %) and chronic alcoholism was found in 15 (28.85 %) patients. Associated diseases found were hypertension in 12 (23.08 %), diabetes mellitus in 5 (9.25%) and chronic renal disease in 3(5.7 %) patients. History of taking anti-platelet drugs was found in one (1.92 %) patient. In our study, the most common diagnosis was right frontotemporoparietal (FTP) chronic subdural hematoma, observed in 40% of patients, followed by left FTP chronic SDH in 32%. Bilateral FTP chronic SDH accounted for 14%, while left acute-on-chronic and right acute-on-chronic variants comprised 6% and 6%, respectively. Rare subtypes included bilateral FTP acute-on-chronic (1%) and septated chronic SDH (1%).Bilateral presentations were less common than unilateral ones. The diagnostic trend in our study reflects typical patterns seen in CSDH literature, with unilateral chronic SDH being the most frequent. In our study, the most commonly performed procedure was right frontoparietal (FP) burr hole evacuation, accounting for 39% of cases, followed by left FP burr hole in 33% and bilateral FP burr in 11%. Mini craniotomies were less frequent, with left frontoparietal (FP) mini craniotomy done in 7% and right FP mini craniotomy in 4%. Bilateral mini craniotomy and decompression procedures were each performed in 1% of patients. Combined left and right FP burr holes were done in 3% of cases. Decompression craniotomies were rare, with only one case each on the right and left sides. Overall, burr hole evacuation remained the predominant surgical approach in our cohort. In our study, the most commonly performed procedure for chronic subdural hematoma was burr hole craniostomy, with right FP and left FP burr holes accounting for 39% and 33% respectively, reflecting global preference for this method due to its simplicity, efficacy, and low morbidity. Mini craniotomies and decompression procedures were performed in selected cases, particularly those with thick membranes, septation, recurrent hematomas, acute on chronic sdh, aligning with broader surgical guidelines that recommend craniotomy for complex or refractory cases. Although endoscopic-assisted evacuation is an emerging technique offering improved visualization, it was not utilized in our cohort. Subdural drains, which have been shown to reduce recurrence by up to 60%, were selectively used, and the recurrence rate in our study was (6.7%), possibly indicating suboptimal drain use or case complexity. Conservative management was not widely employed, as most patients were symptomatic, and medical therapies such as corticosteroids or tranexamic acid were not standard in our protocol. Thus, our surgical approach aligns with established practices, though recurrence outcomes suggest the need for optimized postoperative strategies. In a comparative study by Dr. A. Ravikumar14 (2015) involving 50 patients, burr hole evacuation was performed in 88% of cases, craniotomy in 8%, and twist drill craniostomy in 4%. The study emphasized the preference for burr hole surgery due to its simplicity and lower morbidity. Craniotomy was reserved for cases with thick membranes or recurrent hematomas. Compared to this, the current study shows a broader surgical spectrum, with mini craniotomy used in 12% and decompression craniotomy in 2% of cases, reflecting individualized surgical decision-making based on hematoma characteristics and clinical presentation. In our study, the recurrence rate of CSDH was 6.7%, which was 10–20% reported by Yang and Huang (2017)15 and 21.3% by Choi et al. (2020)16. The recurrence may reflect limited use of drains or more complex hematomas. Mortality in our cohort was 8%, exceeding the 7.4% reported by Choi et al. and the generally lower rates noted by Yang and Huang. Septated hematomas were rare (1%) in our series. Acute-on-chronic cases were 12%. Other studies report higher frequency of these variants linked to recurrence. Our findings suggest a need to optimize surgical technique and follow-up care.

In our study, chronic subdural hematoma was managed primarily through burr hole drainage, reflecting its status as the gold standard. Most patients underwent unilateral procedures, with right-sided surgeries being more common. Despite standard surgical approaches, a recurrence rate of 6.7% was observed, indicating the need for improved postoperative strategies such as consistent use of subdural drains. Mortality was 8%, slightly higher than reported in larger studies, possibly due to delayed presentation or comorbidities. Mini craniotomy and decompression were reserved for complex or recurrent cases. Overall, timely surgical intervention remains crucial, but individualized care and meticulous technique are key to improving outcomes.

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